Republication of "Primary Ankle Arthrodesis vs ORIF for Severely Comminuted Pilon Fractures: A Comparative Retrospective Study"

Abstract

Background: The treatment for highly comminuted pilon fractures remains controversial. The goal of this retrospective cohort study was to compare functional outcomes of primary arthrodesis of the tibiotalar joint (fusion) and open reduction internal fixation (ORIF).

Methods: Patients who underwent primary ORIF or fusion for pilon fractures at our institution since 2000 were identified by Current Procedural Terminology (CPT) code. Inclusion criteria for the ORIF cohort were patients with an AO/Orthopaedic Trauma Association type C3 pilon fracture. Additional inclusion criteria for the fusion cohort were patients whose fractures were deemed non-reconstructable by the treating surgeon. Outcome assessment was determined by the Foot and Ankle Outcome Score (FAOS) and Short Form 36-item health survey (SF-36), time to radiographic union or fusion, and wound-healing complications at a minimum of 2 years after their surgery.

Results: Nineteen ORIF and 16 fusion patients completed the study's outcome assessments. A higher rate of nonunion was observed in patients treated by primary ORIF than primary fusion (5/19 vs 1/16). Posttraumatic arthritis was observed in 11 of 19 primary ORIF patients. Primary fusion patients exhibited increased symptoms, pain, and physical role limits but were equivalent to primary ORIF patients on all other functional metrics examined.

Conclusions: Primary ankle arthrodesis achieves a lower rate of nonunion and comparable functional outcomes to ORIF in patients with severely comminuted pilon fractures. The higher rate of nonunion observed in the primary ORIF group suggests that primary fusion should be considered an effective procedure for severe injuries to decrease the need for further operative intervention.

Level of evidence: Therapeutic Level III, retrospective cohort.

Keywords: AO/OTA type C3; ORIF; arthrodesis; outcome studies; pilon fracture; plafond; retrospective cohort study; trauma.

Figure 1.

Preoperative and follow-up radiographic evaluation. Anteroposterior (A, C, E, G) and lateral (B, D, F, H) radiographs of type C3 pilon fractures upon presentation (A, B, E, F) or after 7 years of follow-up after primary open reduction internal fixation (C, D) or 6 years of follow-up after primary fusion (G, H).

Figure 2.

Outcomes reported by the Foot and Ankle Outcome Score (FAOS). FAOS scores for the open reduction internal fixation (ORIF) patient cohort (n = 19) and fusion patient cohort (N = 16). Data are represented as the mean score, with error bars representing 95% CI. Populations were compared using Wilcoxon Mann-Whitney rank sum to determine significant differences between scores for each category. ADL, activities of daily living; QOL, quality of life; Rec, recreation. *P < .05.

Figure 3.

Outcomes reported by the Short Form 36-item health survey (SF-36). SF-36 scores for the open reduction internal fixation (ORIF) patient cohort (n = 19) and fusion patient cohort (n = 16). Data are represented as the mean score, with error bars representing 95% CI. Populations were compared using Wilcoxon Mann-Whitney rank sum to determine significant differences between scores for each category. Emot, emotional; Funct, function; Gen, general; Phys, physical. *P < .05.

Figure 4.

Short Form 36-item health survey (SF-36) calculated summary scores. Scores for the open reduction internal fixation (ORIF) patient cohort (n = 19) and fusion patient cohort (n = 16) are represented by the inner-quartile range (box) and mean (line), with error bars representing the range of the data. Populations were compared using Wilcoxon Mann-Whitney rank sum to determine significant differences between scores for each category. Comp, component; Phys, physical; Sum, summary. **P < .01.

Figure 5.

Correlation between pain scores reported by Foot and Ankle Outcome Score (FAOS) and the Short Form 36-item health survey (SF-36). Pain scores for the open reduction internal fixation (ORIF) patient cohort (n = 19) and fusion patient cohort (n = 15) as assessed by FAOS and SF-36 were plotted against each other. Linear regression analysis for each cohort was performed. The slope, y-intercept (Y-int), and coefficient of determination (R²) for each fit are reported below its respective population. The slope demonstrates the amount to which patients report similar pain on FAOS and SF-36, with a slope of 1.0 signifying equivalent pain by both surveys, a slope more than 1.0 signifying more intense pain by FAOS, and a slope less than 1.0 signifying more intense pain by SF-36.